The COVID-19 pandemic has exacerbated and bought to the fore the critical nature of a skilled, experienced, and well-trained public health workforce. Data for this study were collected prior to the COVID-19 pandemic, however are more poignant now than ever. Our research key findings can be consolidated into three principal themes: leadership, politics, and communication.
Epidemiology workforce role
The need for local solutions to local problems is increasingly highlighted in the literature.(3,34–37) Our survey found that international responders reported more challenges than national responders in navigating the political environment, collaboration, security, and language. We must begin to think wider than individual roles and reconsider the broader use and role of both local and international responders during emergency response and how they can more effectively interact.
Many of the challenges identified in our study stem from the structure of emergency response. Short deployments of international responders with limited experience and little or no knowledge of the local language, culture, or politics, hampers effectiveness. Our findings showed that national responders have ancillary strengths, such as a better understanding of the political environment, language, and culture, which may better support the identification of local needs and priorities.(38–42)
The Global Preparedness Monitoring Board 2019 report indicated that emergency response systems need to better engage in community engagement during preparedness as well as response.(7) Local actors need to be at the centre of every response to ensure understanding of local context, history, cultural challenges.(34,36) Increasingly, communities are demanding a leadership role within emergency response,(35) and countries are enforcing restrictions on international workers to ensure country coordination and management.(43) It has been noted that although international responders deploy with good intentions, they can obstruct the work on the ground.(43)
Just as the need for a rebalancing of power within the humanitarian aid sector between the Global North and South has been identified,(34) discussions also need to be had within the public health emergency response sector. The inequity of response between the Global South and Global North during the COVID-19 response further accentuates why a review of emergency response framework is needed.(44) We need to begin a global discussion ensuring adequate structures and frameworks for emergency response, and challenge the role of international responders to ensure leadership is centred at the local level to help address the complex challenges.(3,8) Emergency workforce response needs to move towards a national structure where international responders follow the lead of the national public health leadership and responders, and provide technical assistance to fill gaps and enhance capacity.(3,34,38,45)
This research identified the major role categories associated with the epidemiologist in emergency response. More work is needed to define roles by response type as well as to understand the minimum skills and experience needed to competently conduct each role, which in turn would inform the future field epidemiology and public health emergency response training.
Many of the challenges identified in this study are compounded by limited clarification or understanding of responder roles. Formalisation of required capacities and role of the medical and nursing professions during emergency response has been conducted, however, this has not yet been done for the epidemiology workforce.(46) Addressing clarity of roles for field epidemiologists will support effective recruitment, once required skills and experience are further refined. This would also lead to responders being more prepared for deployment, and therefore increasing their effectiveness.(17)
There is a need to sensitise management and the broader emergency response community on the role of the epidemiology workforce so the skills they bring to a response are better understood and productively applied. Training of Public Health leaders and managers has begun in many countries, to broaden the understanding amongst leaders and managers of the value of the epidemiology workforce. We recommend this sensitisation of leaders be conducted within emergency response teams and their collaborators.
Whilst short-term deployment of international responders with limited experience continues, response teams need support mechanisms that ensure the short deployments are effective. Enhanced identification of the national responder needs during response could support more effective targeted international deployments and remote support mechanisms.
In early 2021, the WHO Director-General stated that to strengthen health security, the global health emergency workforce needs investment and strengthening at all levels.(47) Although all levels do need strengthening, the primary focus should be to ensure local workforce support during emergencies to facilitate a reduction in long-term reliance on international deployments. Longer-term measures include addressing human resource issues and team structure to ensure collective competence during emergency responses. This includes training and upskilling of the new and current workforce, accreditation of the epidemiology profession, clarification of roles, defining minimum skills and experience needed for roles, and providing a support system to assist responders whilst working on an emergency.(16) Earlier research into the training gaps identified key areas for workforce support programs such as FETPs to focus on strengthening local workforces.(2) Other workforce support research has identified mentorship-type support helps to mitigate inexperience of the response workforce especially when navigating complex political environments.(48,49)
The COVID-19 pandemic has clearly demonstrated that large public health events require responders with specialist skills and expertise to appropriately address the crisis. The pandemic response has also exposed the political nature of outbreaks and the critical role of politics in defining response direction and decision-making. (3,18,19) Public health specialists and epidemiologists are critical to inform evidence-based decision making, however, the Independent Panel report decried political leadership that either failed to hear or act on this expertise to prevent SARS-CoV-2 transmission and guide control.(18) Our study has highlighted that epidemiology responders often do not understand the political dynamics of an outbreak, or find them difficult to navigate. Politics is a central component of outbreak management, and we need to better equip epidemiologists with political intelligence through future epidemiology training.(37,48,50)
Although our respondents were equally distributed across identified gender, we identified gender-based differences in who received needed support, with males receiving more support. In this increasingly female-dominated field, we need to do better to support women, especially when they request support. These findings are congruent with research and reports identifying gender biases in leadership and gender representation in global health.(3,8,51–53)
When we compared the challenges and roles of national to international responders, we found that national responders were less likely to identify politics as a challenge and they were more likely to engage in cross-sectoral collaborative work. The importance of, and the need for, local based response is well documented in the literature.(39,54–59) Future outbreaks need to embrace this to ensure a one-health approach is taken to emergency response emergency, and collaboration rather than siloed work is essential.
Our research shows a broad range of communication challenges. In a recent study of epidemiology training needs, communication skill development was identified as in need of strengthening.(60) To improve the effectiveness of the epidemiology workforce during emergency response, communication strategies need to be developed. The COVID-19 pandemic has emphasised the need for clear communication, and prompt sharing of resources, information and knowledge. (8,61,62) Improving communication skills of the epidemiology workforce would also support use of evidence to inform the response.(60) Defining and communicating the role of the epidemiologist to decision-makers and emergency responders would also help the broader response community to realise how the epidemiology workforce could be better integrated and utilised during a response.(8,16)
Early consultations with emergency response organisations identified the absence of comprehensive emergency response workforce databases. This meant it was not possible to conduct representative sampling of this population. To lessen the impact of selection bias, we used multiple pathways to recruit participants. As this study included participants representing all WHO regions, we made the survey available in French and English to increase representation. There were varying timeframes between the most recent emergency response and the time of survey completion, potentially leading to different levels of recall. A time lag between responses and completion of the survey may have been advantageous as the individual had time to reflect on their role and the challenges they experienced.(63,64)